Remarks by Mark V. Rosenker, Chairman
National Transportation Safety Board
At the 2007
International Society of Air Safety Investigators (ISASI) Mid Atlantic Regional Dinner Meeting
Herndon, VA
May 3, 2007

 

 


GOOD EVENING LADIES AND GENTLEMEN.  PERHAPS MORE APPROPRIATELY I SHOULD SAY – GOOD EVENING FELLOW SAFETY PROFESSIONALS.

TO FRANK DELGANDIO AND RON SCHLEEDE - THANK YOU FOR THE INVITATION TO SPEAK TO YOUR GROUP TONIGHT.   

TO THE INTERNATIONAL COUNCIL MEMBERS, WELCOME TO THE USA AND TO THE WASHINGTON AREA.  YOUR PROFESSIONAL SOCIETY (ISASI) AND THE NTSB CERTAINLY HAVE MANY THINGS IN COMMON – AND I SEE MANY FAMILIAR FACES AS I LOOK IN THE AUDIENCE.

FIRST, I WANT TO SHARE WITH YOU SOME TOPICS THAT ARE HIGH ON THE NTSB’S LIST OF MAJOR CONCERNS.   AND, BEFORE WE CONCLUDE THIS EVENING, I’D LIKE TO HEAR ABOUT YOUR CONCERNS.  THIS IS AN EXCELLENT OPPORTUNITY FOR ME TO RECEIVE FEEDBACK FROM YOUR TECHNICAL EXPERTISE.   THERE ARE SOME CARDS ON YOUR TABLES FOR THAT PURPOSE.  IF YOU DESIRE, PLEASE JOT DOWN YOUR THOUGHTS, PASS THEM UP TO RON OR FRANK AND WE’LL SEE IF I CAN ADDRESS THEM.   IF WE RUN SHORT ON TIME,  I WILL ASK OUR STAFF TO RESPOND TO YOU LATER, JUST PROVIDE YOUR E-MAIL ADDRESS ON THE CARD.

I HOPE YOU HAVE HAD AN OPPORTUNITY TO USE OUR NTSB WEB SITE  - AS WE ENDEAVOR TO KEEP SAFETY PROFESSIONALS, THE MEDIA, AND THE PUBLIC INFORMED ON OUR ACTIVITIES.  YOU WILL SEE A “NEWS AND EVENTS” HEADING ON THE LEFT SIDE OF THE WEB PAGE - IT CONTAINS THE SPEECHES AND TESTIMONY OF ALL THE BOARD MEMBERS.   IT ALSO CONTAINS A DETAILED HISTORY OF ALL THE PUBLIC HEARINGS, PUBLIC FORUMS, FINAL BOARD MEETINGS, AND SYMPOSIA.

YOU WILL ALSO NOTE ON THE SITE THE MULTIMODAL NATURE OF THE NTSB. THE INTERESTS OF THE NTSB EXTEND TO ALL TRANSPORTATION MODES AND THE RELATED MOVEMENT OF PEOPLE AND PRODUCTS. CERTAINLY WE SHOULD NEVER FORGET THE TRAGEDIES ON OUR HIGHWAYS – WITH THE UNTOLD SUFFERING OF OVER 43,000 DEATHS AND THREE MILLION INJURIES ANNUALLY.

NOW, LET’S TALK ABOUT AVIATION.  WE KNOW THE AVIATION SECTOR IS A VERY SAFE AND EFFICIENT MODE OF TRANSPORTATION.   WE OBSERVE THAT MAJOR AVIATION ACCIDENTS ARE FEW – ESPECIALLY IN RELATION TO THE NUMBER OF MOVEMENTS TAKING PLACE EACH DAY AT OUR NATION’S AIRPORTS.   HOWEVER, THERE IS STILL MUCH THAT CAN BE DONE - AND IT IS OUR JOB TO INVESTIGATE AND MAKE RECOMMENDATIONS THAT STRIVE FOR AN EVEN SAFER AVIATION INDUSTRY.

AS YOU KNOW, OUR TASK IS NOT LIMITED TO COMMERCIAL AIR TRANPORT; WE ARE INTERESTED IN EVERY SECTOR OF AVIATION:  AIRLINES, AIR CHARTER, AERO MEDICAL, AIR TOUR, , BUSINESS, PRIVATE, AND RECREATIONAL FLYING.  AND WE ARE ALSO INTERESTED IN THE SUPPORTING INFRASTRUCTURE FOR THESE SECTORS;  FOR EXAMPLE,  AIRPORTS, THE AIR TRAFFIC CONTROL SYSTEM  AND AVIATION TRAINING INSTITUTIONS.

AS A RECENT EXAMPLE, ON MARCH 27, WE CONDUCTED A PUBLIC FORUM PROMOTING RUNWAY SAFETY.   THAT DATE WAS THE 30TH ANNIVERSARY OF THE PANAM - KLM GROUND COLLISION IN TENERIFE,  CANARY ISLANDS – WHERE 583 SOULS LOST THEIR LIVES.   IT WAS THE WORST AVIATION ACCIDENT IN HISTORY.  DURING THE FORUM, WE HEARD AN ABSOLUTELY RIVETING EYEWITNESS ACCOUNT FROM THE  FIRST OFFICER OF THE PAN AM 747 THAT DAY, CAPTAIN ROBERT BRAGG.   WE ALSO HEARD FROM TEN INTEREST GROUPS OR PANELISTS.   IT WAS MY INTENTION DURING THIS FORUM TO RE-ENERGIZE FEDERAL AGENCIES AND ORGANIZATIONS TO FULLY FOCUS ON SOLUTIONS TO THIS PROBLEM.

AND THE BOTTOM LINE IS THIS –- THE CURRENT AIRCRAFT MOVEMENT SYSTEM, OR AMASS, IS NOT SUFFICIENT.   WE NEED GROUND MOVEMENT SAFETY SYSTEMS THAT WILL PREVENT RUNWAY INCURSIONS AT BOTH LARGE AND SMALL AIRPORTS - AND …IF/WHEN SEPARATION IS NOT PRESENT, THE SYSTEM SHOULD PROVIDE A WARNING OF THE DANGER DIRECTLY TO THE FLIGHT CREW.  WE KNOW THAT DELIVERING TECHNOLOGICAL SOLUTIONS TAKES TIME, BUT WE NEED ACTION FOR TODAY – AND FOR THE FUTURE !

FOR THE SPORT FLYERS IN THE AUDIENCE – AND THOSE INVOLVED IN AOPA SAFETY INITIATIVES AND GENERAL AVIATION AIRPLANES – I HOPE YOU FOLLOWED OUR BOARD MEETING TWO DAYS AGO.  AT THAT SUNSHINE MEETING, THE BOARD REVIEWED THE TRAGIC ACCIDENT IN DOWNTOWN MANHATTAN THAT INVOLVED A SINGLE-ENGINE CIRRUS SR20 AIRPLANE CARRYING YANKEE PITCHER CORY LIDLE AND HIS FLIGHT INSTRUCTOR. THERE ARE SEVERAL LESSONS LEARNED FROM THIS CASE.  WE DIDN’T LET THE HIGH PROFILE NATURE OF THE PILOT OBSCURE THE FACTS – TOO LITTLE AIRSPACE AND TOO LITTLE EXPERIENCE.

WE HAVE SEVERAL AIR TRANSPORT INVESTIGATIONS COMING UP BEFORE THE BOARD             FOR FINAL ADOPTION.   THERE IS THE CHALKS FLYING BOAT ACCIDENT IN MIAMI INVOLVING AN INFLIGHT WING STRUCTURAL FAILURE.   THE SOUTHWEST AIRLINES RUNWAY EXCURSION AT CHICAGO MIDWAY, KILLING A CHILD IN THE SURROUNDING STREET, AND THE CRJ THAT TOOK OFF FROM AN INCORRECT RUNWAY AT LEXINGTON KENTUCKY, RESULTING IN 49 FATALITIES.  IN EACH OF THESE CASES OUR STAFF COULD HAVE TAKEN THE EASY WAY – THE QUICK WAY – TO JUST BLAME SOMEBODY AND MOVE ON.   BUT I CAN ASSURE YOU OF THE FOLLOWING: ONE – THAT THE NTSB IS NOT IN THE BLAME GAME;   AND TWO -  THE NTSB THOROUGHLY RESEARCHES ALL THE SYSTEMIC ISSUES OF AN ACCIDENT AND ATTEMPTS TO CRAFT OUR RECOMMENDATIONS TOWARD ALL THE INITIATING FACTORS.

 THE CHALKS ACCIDENT IS AN OPPORTUNITY TO LOOK, IN THE FINAL REPORT AND RECOMMENDATIONS, AT ALL AGING ISSUES OF THIS CLASS OF AIR TRANSPORT.  THE AIRPLANE WAS 58 YEARS OLD - AND WE FOUND THE INSPECTION METHODS FOR CONTINUING AIRWORTHINESS AND OVERSIGHT TO BE VERY DEFICIENT.  I WILL NOT BE SURPRISED IF YOU WILL SEE THE BOARD’S RECOMMENDATIONS TAKE ON MORE OF A SAFETY MANAGEMENT SYSTEMS APPROACH REGARDING THIS EVENT. 

FOR THE SOUTHWEST AIRLINES OVERRUN – PERHAPS YOU ARE AWARE THAT, SHORTLY AFTER THE ACCIDENT, THE NTSB RECOMMENDED A MAJOR CHANGE IN THE WAY THRUST REVERSE CREDIT IS USED IN PRELANDING CALCULATIONS. ALTHOUGH THE FAA DID NOT ADOPT THE CONCEPT TO ELIMINATE REVERSE CREDIT FOR LANDING DISTANCE ON SNOW AND ICE, THE NTSB RECOMMENDATION DID PROMOTE SPIRITED DISCUSSION THAT HAS PROVED VERY BENEFICIAL TO THE INDUSTRY.   BOTH MANUFACTURERS AND OPERATORS ARE MAKING CHANGES IN THE WAY THEY CALCULATE LANDING DISTANCE ON CONTAMINATED RUNWAYS - AND THE STORY IS FAR FROM OVER.  YOU WILL SEE MORE ACCIDENT PREVENTION ACTIVITIES WITH THE BOARD MEETING ON THIS ACCIDENT.

REGARDING THE LEXINGTON, KENTUCKY CRJ TAKEOFF ACCIDENT INVESTIGATION, IT WOULD BE EASY TO STOP WITH SAYING THAT A CONFUSED YOUNG FIRST OFFICER TOOK OFF ON THE WRONG RUNWAY, AND THE CAPTAIN FAILED TO NOTICE THE ERROR UNTIL IT WAS TOO LATE.   YES – WE COULD STOP THERE.  HOWEVER, THAT WOULD NOT REFLECT OUR SYSTEMATIC APPROACH TO INVESTIGATION THAT ATTEMPTS TO UNDERSTAND THE CIRCUMSTANCES OF THE EVENT AND IDENTIFY WAYS TO PREVENT ITS RECURRENCE.  THE ONGOING INVESTIGATION IS EXAMINING ALL POSSIBLE AREAS INCLUDING AIRPORT MARKINGS, CONSTRUCTION ISSUES, THE NOTAM-NOTICE TO AIRMAN SYSTEM, AIR TRAFFIC CONTROL PROCEDURES, CREW RESOURCE MANAGEMENT, PERSONNEL FATIGUE, AND NEW TECHNOLOGIES IN THE COCKPIT.  THROUGH THE PARTY SYSTEM, THE NTSB STAFF HAS BEEN ABLE TO ASSEMBLE A MULTITUDE OF INPUTS FROM THE FAA, OPERATOR, MANUFACTURER, PROFESSIONAL ASSOCIATIONS AND OTHERS. THIS IS THE SYNERGISTIC APPROACH THAT ADDS QUANTUM VALUE TO MAJOR INVESTIGATIONS – AND TO THE OVERALL INDUSTRY IMPROVEMENTS.  WE DO NOT DO THINGS IN A VACUUM – OUR PROCESS IS OPEN TO ALL.

LET ME CLARIFY THAT COMMENT.  ALL OF THE DATA THAT OUR INVESTIGATORS ARE WORKING WITH IN EACH OF THESE ACCIDENTS ARE AVAILABLE TO THE PUBLIC THROUGH OUR DOCUMENT MANAGEMENT BRANCH.   YES, I MEAN ALL OF IT.   OUR FOREIGN GUESTS MAY FIND THIS A BIT SURPRISING.   AIR TRAFFIC CONTROL TRANSCRIPTS AND PERTINENT COCKPIT VOICE RECORDER EXCHANGES ARE THERE.  THE LAWS OF THE UNITED STATES REQUIRE PRIVACY OF THE ACTUAL CVR TAPE, WHICH IS VERY UNDERSTANDABLE – AND ADDITIONAL PUBLIC ACCESS LAWS REQUIRE PUBLIC ACCESS TO THE TRANSCRIPTS OF THE PERTINENT CVR DATA.  WHEN INFORMATION FROM THE FLIGHT DATA RECORDER IS VALIDATED, THOSE DATA ARE ALSO PLACED INTO THE PUBLIC FILE.   OUR GROUP CHAIRMEN FOR VARIOUS SPECIALTIES IN STRUCTURES, SYSTEMS, POWERPLANTS, OPERATIONS, AND OTHERS ALSO MAKE THEIR REPORTS AVAILABLE ALONG WITH THEIR SUPPORTING ATTACHMENTS.  IN SUMMARY – THE THRUST AND STRUCTURE OF U.S.  FREEDOM OF INFORMATION LAWS PROVIDE NEITHER A BROAD-BASED NOR AN OPEN-ENDED EXCLUSION FOR INFORMATION OR DOCUMENTS RELATED TO THE OVERALL PROGRESS AND TO THE FINDINGS OF AN AIRCRAFT ACCIDENT INVESTIGATION.  WE BELIEVE THIS OPEN ACCESS TO INFORMATION PROVIDES FULL TRANSPARENCY AND A MORE COMPLETE UNDERSTANDING OF THE INVESTIGATION PROCESS.  IN THIS MANNER WE MAINTAIN THE CREDIBILITY OF THE INVESTIGATION AND MAKE A SIGNIFICANT CONTRIBUTION TO AVIATION SAFETY IN EVERY CORNER OF THE WORLD. 

A MENTION OF WORLDWIDE SAFETY EFFORTS LEADS ME TO MY FINAL TOPIC OF THE EVENING.  EVERY YEAR, SAFETY BOARD INVESTIGATORS TRAVEL TO ABOUT A DOZEN FOREIGN MAJOR ACCIDENT SCENES.  GENERALLY THIS IS REQUIRED BECAUSE THE UNITED STATES IS THE STATE OF MANUFACTURE OF THE AIRPLANE OR THE ENGINE AND WE ARE ASSISTING THE STATE OF OCCURRENCE.  THIS ACTIVITY IS EXTREMELY CHALLENGING – JUST CONSIDER THESE EXAMPLES:  MEDAN, INDONESIA, --ABUJA, NIGERIA, --IRKUTSK, SIBERIA,  --MAKASSAR STRAIT, INDONESIA, --YOGYAKARTA, INDONESIA. OUR INVESTIGATORS ARE WORKING SIDE BY SIDE WITH A NATIONAL INVESTIGATION AUTHORITY;  MANY TIMES WITH LIMITED RESOURCES AND WORKING CONDITIONS VERY FAR FROM U.S. STANDARDS.

WE HAVE TWO MAJOR ISSUES, OR FRUSTRATIONS, AT THIS MOMENT REGARDING FOREIGN INVESTIGATIONS.  ONE INVOLVES THE ADAM AIR B737 LOSS OF JANUARY 1, 2007, IN THE SEAS OF INDONESIA.  AS WE MEET HERE TONIGHT, FOUR MONTHS AFTER THIS ACCIDENT, THE FLIGHT RECORDERS REMAIN ON THE OCEAN FLOOR, WITH THE POTENTIAL SECRETS OF EXACTLY WHAT BROUGHT THAT AIRPLANE DOWN, AND HOW TO PREVENT A SIMILAR EVENT IN THE FUTURE.  THE OTHER FRUSTRATION IS THE COMPETING LEGAL AND SAFETY INTERESTS ASSOCIATED WITH THE MIDAIR COLLISION OF THE GOL 737 AND THE LEGACY BUSINESS JET OVER THE AMAZON JUNGLES OF BRAZIL.
ON A BRIGHTER NOTE, OUR INVOLVEMENT IN THE BRAZILIAN INVESTIGATION GAVE US THE DOCUMENTATION WE NEEDED TO ISSUE SAFETY RECOMMENDATIONS YESTERDAY TO THE FAA ABOUT NEEDED AURAL WARNINGS IN THE COCKPIT WHEN THE TCAS SYSTEM GOES OFF LINE.  YOU CAN SEE THAT LETTER ON OUR WEBSITE.

SO I BELIEVE I’VE GIVEN YOU A BRIEF OVERVIEW OF THE THINGS THAT THE NTSB IS DOING.  AS YOU KNOW, WE ARE A VERY SMALL AGENCY – WITH A BIG MISSION – WITH ONLY A LIMITED NUMBER OF STAFF TO GET THE JOB DONE.   WE JUST CELEBRATED OUR AGENCY’S 40THANIVERSARY LAST MONTH, AND WE LOOK FORWARD TO MANY MORE YEARS OF PUBLIC SERVICE.

NOW IT’S YOUR TURN.  LET’S LOOK AT SOME QUESTIONS.